Provider Demographics
NPI:1033173828
Name:BLACKLICK VALLEY FOUNDATION AND AMBULANCE SERVICE INC
Entity Type:Organization
Organization Name:BLACKLICK VALLEY FOUNDATION AND AMBULANCE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERWOOD-BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-749-7332
Mailing Address - Street 1:1077 1ST ST
Mailing Address - Street 2:
Mailing Address - City:NANTY GLO
Mailing Address - State:PA
Mailing Address - Zip Code:15943-1159
Mailing Address - Country:US
Mailing Address - Phone:814-749-7332
Mailing Address - Fax:814-749-7188
Practice Address - Street 1:1077 1ST ST
Practice Address - Street 2:
Practice Address - City:NANTY GLO
Practice Address - State:PA
Practice Address - Zip Code:15943-1159
Practice Address - Country:US
Practice Address - Phone:814-749-7332
Practice Address - Fax:814-749-7188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA031503416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008930680001Medicaid
PA281902OtherPA BLUE SHIELD
PA590001284OtherRAILROAD MEDICARE
PA281902OtherPA BLUE SHIELD